Q: OK, fine. I can see that some media probably affects how people think about and act toward nursing, like maybe a respected newspaper or current affairs show on TV. But how can some TV drama, sitcom or commercial affect people that way? People know enough not to take that stuff seriously!

A: Actually, the effect of that stuff on the audience's views and actions is taken very seriously indeed by the public health community, physicians, the news and advertising industries--and even Hollywood itself.
In the field of public health, the growing efforts to influence the public's health-related views and actions through entertainment media are called "entertainment education."

The mass media is in the business of affecting how and what people think. To believe that people are able to disregard everything they perceive in the entertainment media because the scenarios presented aren't literally "true," or because they are loosely staged simulations of reality (as in "reality" shows), we would also have to believe that people disregard all messages in advertising, since ads commonly present actors and models in simulated situations. But that is simply not how the human mind works. In order for an entertainment show or commercial to be effective, the audience must identify in some way with the characters and what they are doing, even if some aspects of the situation are "unrealistic."

Most people understand that what they are seeing in fictional media products is not a depiction of "real events." In a recent TV ad, when the brilliant female "brain surgeon" and mother expertly demands a certain surgical tool in the OR, then practically commands the deferential "nurse" to buy a certain brand of minivan, we know we are not seeing real health care professionals in a real OR. (see the Caravan ad in Quicktime) The scene, which also included a dopey male "patient" and a goofy male anesthesia professional, didn't show a real surgery. But that does not stop viewers from internalizing messages and signals at conscious and subconscious levels. Despite being "fiction," media products like this can still influence: our views of the vehicle in question (as the advertiser fervently hopes); the ability of women today to become authoritative, powerful professionals, yet to still have a family (presumably this ad was directed mainly at women who would identify with the surgeon); the basic set-up of OR's, the kinds of professionals who participate, how they dress, and what tools they use; and of course, the relative power, knowledge and professional roles of physicians and nurses. Some of this may be unintended, but all of it sells the minivan to the target demographic. All of the elements above contribute to the high credibility of the "surgeon," who is, after all, doing the selling.

Indeed, most people would probably admit that this very ad has some positive general influence on society's view of women in the workplace. It shows a skilled, knowledgeable woman doing highly esteemed work that would have been unthinkable for women 50 years ago, yet not sacrificing her ability to raise children in a responsible, loving way. Of course, the relevant difference--the reason the ad's positive influence is more likely to be acknowledged--is that there is broad understanding that women can now be physicians, and that gender bias in the workplace is wrong. By contrast, nursing is not well understood, and society has little basis to understand the significance of or even recognize anti-nurse bias. That is what The Truth About Nursing seeks to change.

The idea that fictional media can influence public views and conduct is not controversial in the field of public health. As with news items, the public health community understands the influence of entertainment programming in health matters very well. "What has become increasingly clear in recent years is that fictional television can also play a significant role in shaping public images about the state of our health care system and policy options for improving the delivery of care." (Turow and Gans, "As Seen on TV: Health Policy Issues in TV's Medical Dramas," Report to the Kaiser Family Foundation, 2002, p. 1) "An important aspect of health communications today is working with the entertainment media to include or improve health messages in popular programs."(Deborah C. Glik, ScD., "Health Communication in Popular Media Formats," American Public Health Association Annual Meeting presentation, 2003, p. 2) This is because "[m]any groups have come to believe that entertainment media can play an important positive role in educating the public about significant health messages."(Kaiser Report, Henry J. Kaiser Family Foundation,"Entertainment Education and Health in the United States.", 2004, p. 1) Conversely, "there is also a great deal of ongoing research evaluating unhealthy messages portrayed in the entertainment media."(Glik p. 2) For instance, public health professionals have devoted significant efforts to "the issue of smoking in movies, which has been shown to influence rates of teen smoking." (Id.)

Turow and Gans have explained the special importance of entertainment television:

Certainly TV dramas reach a much wider audience than most news programs. Beyond the size of their audience, some media scholars argue that entertainment TV's impact can be even more powerful than news in subtly shaping the public's impressions of key societal institutions. The messages are more engaging, often playing out in compelling human dramas involving characters the audience cares about. Viewers are taken behind the scenes to see the hidden forces affecting whether there's a happy ending or a sad one. There are good guys and bad guys, heroes and villains and innocent bystanders. Instead of bill numbers and budget figures, policy issues are portrayed through the lives of "real" human beings, often in life-and-death situations. These health policy discussions take place not only in hospital dramas, but also in dramatic storylines on programs like "Law and Order," "The Practice," and "The West Wing."

Hospital dramas provide an opportunity for viewers to learn specifically what goes on at the center of high-intensity medicine. The dramas' fictional presentations open curtains on relationships between doctors and nurses, specialists and generalists. In ways that news reports cannot, they play out various assumptions about how health care ought to be delivered, about what conflicts arise that affect health care, and about how those conflicts should be resolved and why. Doing that, hospital dramas represent an important part of viewers' curriculum on the problems and possibilities of health care in America. (Turow and Glans, pp. 1-2)

Even more to the point, in explaining why they chose to evaluate discussions of health policy issues in every single prime time U.S. hospital drama episode in the entire 2000-2001 season, Turow and Gans stressed that the dramas' "consistent focus on the relation of doctors and nurses with patients who are in jeopardy make them the source of many viewers' understandings of how the health care system works." (Turow and Gans, p. 4)

Because of the great influence of entertainment media on people's thoughts and actions, "[i]n the United States and around the world, public health organizations are increasingly turning to entertainment media--from soap operas to sitcoms to reality shows--as a way to reach the public with health messages." (Id) This growing effort is often called "entertainment education." Entertainment education is "a way of informing the public about a social issue or concern" by "incorporating an educational message into popular entertainment content in order to raise awareness, increase knowledge, create favorable attitudes, and ultimately motivate people to take socially responsible action in their own lives." (Glik p. 2 citing Singhal & Rogers, "Entertainment-Education: A Communication Strategy for Social Change" (pdf) 1999, emphasis added) Entertainment education is distinct from the use of public service announcements (PSAs), which "can also be an important tool in public health communication," though "[s]ome groups have been effective in combining PSAs with entertainment education for a wider impact." (Kaiser Report p. 1)

"Television is the primary medium for entertainment education in the United States," and recent social and health issues addressed using this strategy include substance abuse, immunization, teen pregnancy, cancer, and HIV/AIDS. (Id.; see Glik p. 2) While entertainment education can come about in different ways, much of it results from "outreach efforts of special interest groups or health agencies to deliver their message to audiences. These groups often work with Hollywood-based advocacy organizations that serve as liaisons to the entertainment community via industry forums, roundtable briefings, and technical script consultations."(Kaiser Report, p. 1)

Among the respected organizations devoting significant resources to entertainment education in recent years are the Harvard and UCLA schools of public health. (Kaiser Report pp. 2, 3, 7) In addition, since 2002, the Annenberg Norman Lear Center's Hollywood, Health & Society project at the University of Southern California has collaborated with producers of prime time shows and soap operas to place messages on a wide variety of health topics, including infectious diseases, diabetes, mental health and health care access. (Glik p. 2; Kaiser Report p. 3.) This project is a joint venture whose sponsors include the Center for Disease Control and the Writers Guild of America, and its board is full of prominent figures in the media, public health, and government. (Hollywood, Health & Society) And the respected Kaiser Family Foundation "has worked with a variety of networks and shows to incorporate health messages into popular entertainment programming. For example, the Foundation organizes annual briefings for the writers and producers of the NBC drama 'ER,' which have resulted in numerous storylines on topics such as rapid HIV testing, emergency contraception, chlamydia, insurance coverage of experimental treatments, teen sexual activity, the working uninsured, and Medicare and Medicaid."

Nor are the health community's entertainment education efforts confined to the developed world. A December 2004 AP story, "Cambodian soap mixes health ed, love," describes a new 60-episode Cambodian television soap opera created by British soap guru Matthew Robinson and funded by the BBC World Service Trust in order to educate Cambodians about disease, especially HIV/AIDS. "Taste of Life" ("Roscheath Chiveth" in Khmer language), which the piece calls Cambodia's "first soap opera," reportedly "follows five student nurses and a student doctor as they move through a nursing college, the local pub and 'Friendship Hospital.'" The fact that the BBC World Service Trust is devoting $6.4 million to the three-year campaign of which the soap is a part underlines the importance of this mechanism for influencing the public. Indeed, this is one mass media product whose makers will presumably not be claiming that their work could not possibly affect how people act as to how health issues: executive producer Matthew Robinson, who was a producer of the popular U.K. soap "Eastenders," is quoting as saying that if the shows do not change behavior, "then the campaign's a failure." Of course, the Truth has some concerns about how nursing might be portrayed in "Taste of Life," but the point is that responsible development professionals view the fictional entertainment media as an important way to influence the public's health actions and attitudes.

However Hollywood may resist The Truth About Nursing's contention that its powerful misportrayal harms nursing, it showslittle doubt about its real world influence when it can claim a positive effect. Indeed, many leading Hollywood figures are intensely proud of their commitment to improving health through entertainment. In presenting a former "ER" executive producer (and physician) with a public service award in December 2003, the Writers Guild of America lauded him for "creating a culture of medical accuracy and groundbreaking realism that revolutionized the primetime landscape," and asserted that his "passion for medical accuracy has paid dividends to the American public, as a recent Harvard study revealed most Americans learn more about health-related problems from series television like ["Law and Order: Special Victims Unit"] than from their own doctors."(WGAw, 2003) (This physician, in addition to executive producing "SVU," is co-chair of Hollywood, Health & Society, and he teaches health communications at USC. (Id.))

Likewise, in the cover story of the February 14, 2004 issue of TV Guide, an "ER" medical advisor and executive producer were eager to celebrate the show's apparent influence on the number of women pursuing emergency medicine, and on the increased popularity of that medical specialty generally. (Truth: Nursing) The story itself went even further, linking the show to an increase in female enrollment at medical schools and calling its impact on the culture "undeniable."(Id.) And in a November 2003 letter to the Pulmonary Hypertension Association, an "ER" story editor (and physician) admitted that those responsible for the show "recognize the capacity of ER to educate the public about diseases and we take this responsibility seriously."(Truth: Dear "ER") Of course, the same "ER" personnel who celebrate how the show has improved the world through its portrayal of ED physicians and the diseases they treat seem unable to see how its inaccurate depiction of nurses as peripheral subordinates could have a negative effect.

Moreover, by contrast to the traditionally passive role of nurses, physicians have moved aggressively to influence Hollywood's portrayal of them and health care generally for decades, just as they have with the news media. (See Buresh & Gordon, From Silence to Voice, 2013; Buresh & Gordon, "Doc Hollywood," 2001) "Physicians have always had a symbiotic relationship with Hollywood," which "has been an active partner in the creation of a heroic medical narrative that has shaped Americans' view of health care...and conferred status on medical practitioners and specialists. This narrative places physicians at the center of the health care stage."(Buresh & Gordon, "Doc Hollywood") Indeed, "[t]he TV landscape has rarely been without a major medical drama since the early 1950's, and the medical community has kept a close watch on its fictional counterparts since then."(Chocano, 2002) And "[a]s Joseph Turow documented in his book Playing Doctor: Television, Storytelling, and Medical Power, medicine has exacted a high price for its cooperation and seal of approval," expecting the industry to "portray doctors and their treatments in the best possible light, reinforce their conservative values, and support the kind of public policy and scientific agendas doctors favor."(Buresh & Gordon, "Doc Hollywood") In fact, physicians' Hollywood image has been so important to them that some reportedly "worried that [Marcus] Welby's incredibly solicitous and loyal bedside manner was leading their patients to question why they did not act towards them as Welby would."(Chocano)

In recent years, physicians have published analyses of the impact of entertainment programming on the public--and even on medical professionals themselves--in respected medical journals. In 1998, after "ER" had been on the air only a few years, one such article addressed the show's effect on the career choices and professional development of medical students. It concluded that "[m]edical students' reactions to televised medical dramas like 'ER' suggest that they may incorporate the attitudes and beliefs of physicians on television in much the same way they acquire the qualities and behaviors of physicians through their experiences in patient care."(O'Connor, "The Role of the Television Drama ER in Medical Student Life: Entertainment or Socialization?." Journal of the American Medical Association, 1998) The article cited other research demonstrating the dramatic growth in ED medical residencies since the show's 1994 premiere. (Id.)

In 2000, several British physicians reported that their extensive examination of recent popular health-focused television dramas had revealed a marginalizing of the important work of anesthetists. (Williamson, Gordon & Lawler, "The anesthetist in medical soaps," Royal College of Anaesthetists Bulletin, 2000 (pdf)) They concluded: "Does it matter that the dramatised anaesthetist is nearly always secondary? Does it matter that the anesthetist rarely has any impact on the outcome of the fictional patient? We suggest that it does. ... Public confidence can only be enhanced if they know that anesthetists are well trained, experienced and above all, highly skilled."(Id.)

Today, physicians provide virtually all significant expert health care advice for entertainment programming. They are the ones who consult on scripts. "ER" was created by physician Michael Crichton, and a number of its writers have been physicians. Physician characters now may be more diverse and have "rougher edges and messier personal lives,"(Buresh & Gordon, "Doc Hollywood"), but "ER," "Scrubs," and "Strong Medicine" regularly present millions of viewers with an unrealistically physician-centric vision of health care, while countless other shows do so whenever they deal with health issues. (See Truth's media reviews; Truth's campaigns and letters) Even portrayals that highlight physicians' perceived flaws tend to present them as tragic heroes. And physicians are still commonly shown controlling--and often actually providing--care that nurses or other health professionals generally do in real life. Thus, "despite the recasting, the basic story remains remarkably true to formula and has a disastrous impact on our social image of caregiving." (Buresh & Gordon, "Doc Hollywood")

Recently, some physicians have even objected to the tragic flaws that make the current crop of fictional physicians more believable. In September 2005, two Boston medical residents (and clinical fellows at Harvard) published a piece in Slate entitled "Paging Dr. Welby: The medical sins of Grey's Anatomy." Authors Ingrid Katz and Alexi Wright made some good points about the ABC hit's damaging medical inaccuracies and distortions. But their main theme seemed to be that things would be better if the American Medical Association had never lost its tight control over how physicians and presumably all health care events are portrayed, which has supposedly led to unsavory depictions of physicians as deeply flawed humans, rather than the godlike Welbys of yesteryear. This, along with medical inaccuracies generally, evidently works to undermine vital public trust in physicians. Among other problems, the piece overlooks the media's ongoing portrayal of physicians as the heroic (if human) providers of all important health care, and the enormous influence individual physicians--like them--continue to wield over such depictions. But the physicians' article clearly reflects the view that such media depictions affect how the public thinks and acts as to health care.

Nursing, with virtually no meaningful input on Hollywood programming, has with few exceptions endured regressive, inaccurate images for decades. These range from the obvious "naughty nurse" stereotypes of "Nightingales" and "The Man Show" to the far more sophisticated "handmaiden" image presented by "realistic" dramas, epitomized by "ER."(See Kalisch & Kalisch, 1980's; Truth's media reviews.)

The news media is also ready to accept that entertainment programming affects viewers' health-related actions--under the right conditions. The February 2004 TV Guide cover story discussed above, which showed such eagerness to accept that "ER" had had a huge positive impact on ED medicine and women in medicine, is an obvious example. (Truth: Nursing) Of course, TV Guide has ignored the Truth's "ER" campaign, though it did take the time to ridicule the Truth's contention that the soap opera "Passions"'s long-term use of an orangutan to play a private duty nurse could possibly have a negative affect on nursing. (Truth: Passions)

The media's reactions to statements that it has a ground level effect vary not only by whether it is receiving praise or criticism, but also by how much respect the media has for the group drawing attention to its performance. Not all advocates who have protested the entertainment media's real world effect have faced the level of skepticism that nurses have. Few would answer the charges of a civil rights group that a general audience television show is blatantly racist or sexist by asserting that it doesn't matter if the show is bigoted or not. The argument would be about whether the show really is sending a bad message. And this is not just true of groups that share largely immutable traits that have historically been the basis for horrific legal and social discrimination, such as ethnic minorities or women. It is also true of complaints from those who represent people with more control over their group status, such as particular professions.

Consider the July 25, 2004 issue of the Baltimore Sun. The Sun had, to our knowledge, taken no
steps up until that time to cover any of the nursing-in-the-media issues the Truth pursues, despite several significant, personal pitches from Truth staff, the urgency of the current nursing crisis, and the obvious hometown angle. (The Sun did run a lengthy, substantive
article about the Truth in November 2006.) But on July 25, 2004, the Sun's Arts & Society section carried Kirstin Valle's interview with the president of the Kentucky-based Center for Rural Strategies under the headline "Reality vs. myth: how we perceive rural America." In 2003, the piece reports, this group "waged a successful campaign against CBS' plans for the show 'The Real Beverly Hillbillies,' which would have documented an uneducated rural family living in Beverly Hills." The group had also recently launched an attack on UPN's reality show "Amish in the City." Ms. Valle did not ask the group's leader how mere entertainment shows could possibly affect the real lives of rural people. Instead, the president was able, without challenge, to deliver comments like this: "Culture is powerful. It's hard to talk about what's going on in rural communities without talking about the culture and how these rural communities are perceived."

Even more telling, on the front page of that same issue, the Baltimore Sun ran Allison Klein's "Art trips up life: TV crime shows influence jurors." This lengthy piece suggested that "the CSI effect" was leading to acquittals in criminal cases because of jurors' unrealistic "expectation of futuristic hard-science evidence." A series of prosecutors and criminal justice figures were permitted to express their views, without challenge, that the popular "CSI" shows were actually affecting judicial results. There was no indication that the Sun had even sought comment from the CSI shows, nor was there a citation to any research, a quote from a defense attorney questioning the real impact of "the CSI effect," or even a juror stating specifically that he or she was influenced by CSI. By contrast, The Truth About Nursing frequently encounters skepticism when it argues, with support, that the mass media, especially "realistic" shows like "ER," affects nursing. And media coverage of the Truth's activities often includes contemptuous comment from Hollywood figures and even some journalists, who evidently can't imagine that the media could have any such effect.

A more recent article, from January 2006--Linda Deutch's AP piece "Legal TV Dramas Influence Real Jurors"--does at least seek comment from Hollywood and a defense attorney. The Hollywood figures stress that they're creating entertainment, but they do not deny having a real world effect. Indeed, "Law and Order" creator Dick Wolf claims credit for having "raised people's awareness of how the justice system operates." The AP piece leaves readers with the clear impression that shows like "CSI" and "Law and Order" are having a significant effect on the real-life criminal justice system. Of course, we have been making the same argument about hospital dramas for years, but we are still waiting for one of the world's most influential press entities to publish a piece headlined "Hospital TV Dramas Influence Nursing Crisis."

What accounts for this stark difference? Well, there is one obvious factor: those arguing for the "CSI effect" are highly respected, powerful attorneys and law enforcement figures, not members of a group that much of the media still views as composed of marginally skilled handmaidens whose work is of little consequence. The Sun article cited a forensic scientist and professor for the idea that the television CSI's are shown doing the work that about four different people do in real life, and that this has resulted in many university students coming into his criminal justice classes to train for jobs that don't actually exist. No producer was quoted saying that Hollywood must be allowed some dramatic license, as was the case when the Truth argued in 2003 that "ER"'s relentless depiction of physicians doing the work of nurses was harming nursing, and ultimately patients. In fact, "ER" commonly shows physicians doing at least four jobs as well: that of physician, nurse, social worker, and respiratory therapist. But rather than include any skeptical comment as to the multiple job CSI problem, the Sun instead allowed the forensic scientist to close the article with his view that the CSI misportrayal was "absurd."

Another recent indication of Hollywood's power to affect real professions and society's overall wellbeing appears in the August 4, 2005 edition of The New York Times, in David M. Halbfinger's piece "Pentagon's New Goal: Put Science Into Scripts." The piece reports that the Pentagon has made significant grants to train an "elite" group of scientists to write screenplays, and to promote closer consultations between scientists and the entertainment industry, especially in the creation of scripts. The Times summarizes the reasoning behind this effort to address "what officials call one of the nation's most vexing long-term national security problems" as follows:

Fewer and fewer students are pursuing science and engineering. While immigrants are taking up the slack in many areas, defense laboratories and industries generally require American citizenship or permanent residency. So a crisis is looming, unless careers in science and engineering suddenly become hugely popular, said Robert J. Barker, an Air Force program manager who approved the grant. And what better way to get a lot of young people interested in science than by producing movies and television shows that depict scientists in flattering ways?

The lengthy article is not without humorous asides as to the apparent mismatch between hard-core scientists and Hollywood. But it contains no media comment to the effect that the Pentagon is crazy to think that the fictional media has any effect on real scientific professions. Indeed, the photo accompanying the article shows "[s]cientists and 'CSI' writers at an American Film Institute workshop."

On October 8, 2006, the Orange County Register ran an extensive piece by Lisa Liddane, "Paging Dr. Nielsen: TV medical shows." The piece examines the extent to which highly popular hospital dramas like "Grey's Anatomy" both reflect and shape real life health matters. It also discusses the history of such shows. The piece quotes show producers, physician writers, and public health experts. All confirm that although such shows are fiction, they have a real effect on how the public thinks and acts as to health care. Vicky Rideout, vice president and director of programs for the study of entertainment media and health for the Henry J. Kaiser Family Foundation, even notes that "TV medical dramas contribute to agenda-setting--and influence how people look at situations and professions." However, the article discusses only how the shows deal with health conditions and overall care settings, not the roles of specific professions. Rideout also notes that shows can affect views through omissions, but again, this idea is not applied to the health professions. The article describes the Foundation's research showing the effect of "ER." The piece suggests--sometimes through quotes from physician show writers--that shows have a responsibility to be as "medically accurate" as they can.

And on November 13, 2006, the Los Angeles Times ran a lengthy and similar piece by Susan Brink headlined: "Prime time to learn: In law dramas, medical shows and comedies, science is invading TV story lines. Good thing they try to get it right." As the title suggests, this piece also examines the growing role of realistic-seeming health themes and issues in major television shows. It includes exhaustive analysis of the various hospital shows of recent decades and health issues they have addressed, and, like its Orange County Register predecessor, has many quotes from producers, public health advocates, and physician advisors. It also discusses the growing importance of the international "entertainment education" movement, and the extensive public health research on which it is based. It notes that serial television can be especially influential because show viewers are exposed to so much programming and become so attached to the characters.

Both of these late 2006 pieces ignore nursing and the arguments of advocates like the Truth
that Hollywood's overall depiction of the profession has been highly inaccurate, despite the presence of physician writers and advisors. Not a single nurse is quoted in either piece. Moreover, though dramatic license and inevitable inaccuracies are mentioned, no one quoted argues that the products under discussion could not really have any effect on the real world because they're fiction. On the contrary, the pieces stress just how influential serial TV depictions can be on the public's health-related conduct, and the need to be as accurate as drama allows. But despite a passing reference to the impact of television on public perceptions about professional roles in the Orange County Register piece, neither piece discusses that topic. Once again, it would appear that much depends on longstanding assumptions about the nature and importance of the subject being portrayed or discussed. Rideout's point about the effect of omissions is a telling one, and not just for television: both of these newspaper articles, which purport to be comprehensive looks at hospital show accuracy, clearly assume that only the work and opinions of physicians matter.

This is an era of media saturation, content diversification and technological development, where it is increasingly difficult even for those with an interest in understanding the world to tell what is "real." In such an environment, there is little doubt that "fictional" media affects how people think and act.